2nd opinion on foot procedure

coder067

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How would you code this??? 28297 and 28310 or 28298?
The patient was properly identified, brought into the operating room, and placed on the operating room table in a supine position. Following administration of the general sedation, a total of 20 cc of 0.5% Marcaine plain was infiltrated in proximal V-block type fashion surrounding the first metatarsal cuneiform joint as well as the base of the first digit. The left foot was then scrubbed, prepped, and draped in the usual sterile and aseptic fashion and elevated for approximately 3 minutes out at which time a previously applied a well-padded thigh tourniquet was inflated to 300 mmHg.

Preoperatively, sandbag was placed to allow for adequate exposure of the operative limb.

Next, a linear incision was planned and performed at the first metatarsocuneiform joint region and blunt as well as sharp dissection was carried down and care taken to retract all vital neurovascular structure and cauterize all bleeders down to the level of the first metatarsocuneiform joint. Careful capsular dissection was carried out to allow for proper anatomical closure.

Attention was then directed to the distal aspect of the footwear where a curvilinear incision was planned and performed of approximately 5 cm at the metatarsal head region and ending just proximal to the hallux interphalangeal joint region. This incision was deepened in the same plane with care taken to retract all vital neurovascular structures and cauterize all bleeders as necessary. A transverse tenotomy and capsulotomy was performed to the entire length of the incision, proximal to distal in the transverse arm at the first metatarsal head region just proximal to the metatarsophalangeal joint region. The periosteal and capsular structures were resected free from its underlying cortical bone and a McGlamry metatarsal elevator was introduced into the wound to free off the adhered sesamoid apparatus. The extensor hallucis tendon was then tenectomized and intraoperative inspection noted articular cartilage to be free of the erosions along its entire dorsal to plantar surface. A sagittal saw was utilized to resect the hypertrophic medial eminence of the first metatarsal with care taken to preserve the plantar crista and sagittal groove. The second dome was removed from the field in toto.

Attention was then directed to the metatarsocuneiform joint region where a laterally based wedge of bone was removed with a sagittal saw encompassing the joint level. This allowed for adequate closure of the 1-2 metatarsal angle. Additional resection of the lateral side of the first metatarsal was carried out to translocate the first metatarsal laterally to also reduce the 1-2 metatarsal angle. Permanent fixation was gained utilizing two screws placed according to standard AO technique in a crossed type fashion with care taken to cross the plantar cortex of the bone and were tied to two finger tightness. An excellent reduction of the deformity was noted and the screws were placed utilizing image intensification. Slight plantar flexion of the first metatarsal was obtained prior to screw placement and the redundant dorsal shelf of the first cuneiform was resected utilizing a rongeur and bone rasp at this time. The wound sites were then flushed with copious amounts of normal sterile saline of all debris. The deep fascial tissues were reapproximated utilizing 3-0 Vicryl in a running suture in simple interrupted suture type fashion.

Attention was then directed to the first proximal phalanx where a linear periostomy was planned and performed medial to the extensor hallucis longus tendon and periosteal and capsular tissue was resected medially and laterally from proximal aspect of the phalanx. At this level, a medially based Akin osteotomy was performed in an oblique fashion with apex oriented distal laterally. A wedge of bone was removed and excellent reduction of deformity was noted and permanent fixation was gained with a 2.0 cannulated screw perpendicular to the osteotomy and utilizing standard AO technique. Image intensification was then used to obtain final anteroposterior oblique and lateral views of the foot. The bunion was reduced anatomically. All wound sites were flushed with copious amounts of normal sterile saline of all debris. The deep fascial tissues were reapproximated utilizing 3-0 Vicryl in a simple interrupted suture type fashion. The subcutaneous tissue was reapproximated utilizing 4-0 Vicryl in a running suture type fashion. The skin was reapproximated utilizing 4-0 nylon in alternating horizontal mattress in simple interrupted suture type fashion.
 
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